I’m guessing if you are reading this then you are probably a manual therapist, and probably pissed off with the title of my blog that’s just called into question your skill, your training and your experience! But before you ‘blow a fuse‘ and head down to the comments section, please hear me out and continue to read on a little further!
It had a mixed response, some agreeing, some disagreeing, so I thought I would expand on this a bit more and explain why I think that there is NO ‘technical’ skill needed to apply ANY manual therapy.
Anyone can do manual therapy
I believe anyone can ‘do’ manual therapy well, without any formal training, without any great experience, without any expensive post graduate courses and exams, and get just as good, if not better results than so called highly skilled professionals.
In fact know it!
This is purely anecdotal, but I’ve had an ongoing neck issue for years now, that grumbles now and then and is often aggravated by spending too long on laptops blogging or tweeting.
Now I’ve sought the help of many professional therapists over the years for this, but the best ‘treatment’ I get without a shadow of a doubt are my wife’s neck massages (that’s when I can convince her to give me one) and she isn’t a trained manual therapist, in fact she doesn’t even work in the healthcare industry.
And I’m not alone, I hear of many others who say similar, that a partner, a friend or an ‘acquaintance’ who isn’t trained in manual therapy gives them a great back rub, head massage or even clicks something now and then that hits the spot and feels ooooh sooooo good.
It’s this, amongst other things that I will get on to, that got me thinking, how is this possible? How is it that my wife makes my neck feel so much better, compared to a £50+ per hour highly trained professional?
Well many argue that this example isn’t a fair comparison, that there are many other factors that a professional therapist just cannot reproduce, such as higher levels of familiarity, relaxation, playfulness etc. But that is exactly my point. It is these non specific factors and not the technical application of manual therapy that makes it more effective, and this is EXACTLY why it raises some BIG questions around the belief many therapists have about technical skill with all manual therapy.
Human touch can be powerful
Many mistake my constant skeptical critique of manual therapy as me saying it doesn’t work or it doesn’t have a role. That’s just not true, and a false dichomtomy and pisses me off hugely, please stop it.
Yes in my opinion manual therapy is over hyped, over used, and surrounded by heaps of pseudoscience, marketing and gimmicks. But there is no denying that human touch can be, and is a very powerful tool. There is also evidence that explains how touch is part of our evolutionary development as mammals, and how it helps us bond and form social groups, relieves pain, both physical and emotional. Simply put touch is soothing, calming and relaxing (source, source).
But what I am highly critical and skeptical about is those who try to make this process of simple, caring, soothing touch over complicated, over technical and over hyped in its application!
Now before I go any further, let me tell you my story with manual therapy just in case you mistake my opinions as being ill-informed or inexperienced. You could not be further from the truth.
My training and education in manual therapy extends well over a decade and is extensive, wide ranging and unfortunately for me been really, really bloody expensive. I have completed all of the well recognised post grad courses in manual therapy, and a few of the other not so well recognised ones. I have been taught by some of the worlds most influential figures in this field. I’ve gained qualifications, sat exams and jumped through the hoops of observed assessments and viva’s. Some would class me as ‘skilled’ manual therapist, but as I’m arguing against this exact fact I won’t!
What is manual therapy?
Manual therapy means different things to different people. When I say manual therapy I mean anything that involves one person being touched, pressed, rubbed, poked, pulled or cracked by another with a hand, finger, foot, elbow, knee or even some tool or device in a so-called ‘therapeutic’ fashion.
Manual therapy exists under bewildering array of names, some well-known ones like massage, manipulation and mobilisation. Sometimes they have more complex and ‘scientific’ sounding names like effleurage, petrissage, myofascial release or deep transverse frictions. Some have more exotic and glamorous titles like Tunia, Graston, Active Release Techniques, and then there are those named after their influential creator such as Rolfing, Maitland or Bowen.
Although all of these techniques have different methods of rubbing, pressing, pulling or poking, the one thing they all have in common is they all have a course or series of courses to attend, and a test to pass to show you have acquired the ‘skills’. Some of these courses last a few days, others longer, with the costs ranging from a few hundred quid to thousands of pounds, dollars or euros. I dread to think the total cost of my manual therapy training but I guess its over £5000.
Now if you do have cash to burn, and you really would like some help in deciding which manual therapy course to take next, I’ve done a helpful little flow chart below to help you out…
Anyway, each technique/method is thought to achieve its effects via different mechanisms, and they all vary in their thinking and explanations how this is achieved. However, one thing that is the same with all of these methods, is they are all based around the notion of changing a structures position, length or freedom to move. Be it a muscle, tendon, ligament, fascia or a joint. They all attribute the positive effects of their manual therapy technique to these factors and ignore the effects of touch on the central and peripheral nervous system, as well as ignoring the host of other non specific factors that manual therapy achieves.
And more annoyingly they all think that their method is far superior than the other methods, with such an air of snobbery and self-imposed hierarchy it is one of the reasons I dislike the manual therapy industry and its guru’s so much.
But the other reason why I dislike the manual therapy profession so much, and why I am being highly critical of it, is that after spending many thousands of pounds, and many years of my time, being taught and lead to believe that manual therapy is a big powerful tool that can help ‘fix’ or ‘cure’ people in pain. I have come to realise that this just isn’t the case. Manual therapy is not as powerful or useful as many claim, it’s certainly not as specific and lets get to the crux of my blog… there is NO technical skill needed!
This annoys me, frustrates me, and pisses me off immensely. Firstly because I feel cheated, mislead and lied to, and secondly because I see that it continues to happen right now, all the time, to many other therapists. In fact the myths and misconceptions about manual therapy seem to be growing stronger and more fanciful as time goes on, and nothing seems to be changing.
A slow realisation
I came to realise that manual therapy isn’t all I’ve been taught or lead to believe slowly, and that’s even with my own strong natural skeptical side always whispering in my ear “this just ain’t right mate”
I began to notice that the results of all these manual therapy methods were highly variable, despite my extensive training, despite my detailed assessment and skilled application. I also began to notice that when I didn’t do the technique exactly the way I was supposed to it didn’t change the outcome or result one bit, some got better, some didn’t as usual.
So I began to ‘experiment’ more and more, and began to realise more and more that actually it didn’t matter how I poked, prodded or rubbed someone. Eventually, I stopped all the ritualistic, pseudo scientific assessments that I had been taught, such as looking for, and feeling for a joints position or movement, poking soft tissues feeling for knots, bands, spasms etc.
Instead I started to talk and listen to my patients more, much more. I spent time finding out what their beliefs, experiences and more importantly their expectations and understanding of manual therapy! I found that by asking patients these questions it allowed me to gage IF manual therapy was suitable, appropriate and even if it is wanted by a patient, not automatically assumed it is based on my assessment.
Research, evidence and an awaking
I then began to read more, a lot more. I looked at the ‘evidence’ with an increasingly critical mind, looking at the method and result sections of the research papers first, even brushing up on my statistics. What I found was most of the research is flawed with methodological design issues and biases so big they dwarfed my own.
I then read more and found therapists and researchers who believed in an open, honest and rationale view of manual therapy, taking into accout all the variable and factors that cause effects with manual therapy, not just the physcial and biomechanical. Researchers such as Bialosky, Zusmann, Gifford and Lederman. I read more and more around pain and neuroscience, human behaviour, and psychology from experts such as Sapolsky, Quintner, Shacklock, Moseley, Butler and many others.
I found other therapists online who were also disenchanted with the biomechanical myths around manual therapy, and they pointed me towards even more research and more evidence, making me question everything I had been taught.
I learnt that you don’t need to mobilise or manipulate a joint in a specific direction, based on a pattern of pain or specific assessment of movement and joint feel (Chiradejnant 2003, Aquino 2009, Schomacher 2009, Nyberg 2013)
I learnt that palpation of muscles, joints, trigger points are all very unreliable and leads therapists to misdiagnose often and direct treatment down wrong and ineffective pathways. (a blog I have done on palpation with all the supporting evidence is here.)
I learnt that when all the different methods and techniques of manual therapy are examined through the process of systematic reviews and meta analysis, most of the research is poor and even the good research shows that it doesn’t do much (Menke 2014, Kumar 2014, Artus 2010, Kent 2005)
It has been a revelation, an awaking. A slow and gradual opening of my eyes, but they are wide open now, so I can now confidently say…
There is NO skill in manual therapy, and it really doesn’t matter how you do it.
Now having said all that there are a some caveats that a manual therapist does needs skill in.
Although the risk of causing any structural damage to connective tissues is small, there are some high velocity techniques that do potentially have a risk of harm and potentially life threatening injuries.
High velocity manipulations, end of range traction and even joint mobilisations to the upper neck have been documented to cause some rare but serious injury’s and in some worst case scenarios, death (source)! So it goes without saying that a full awareness and identification of those at risk as well as ensuring the application of the techniques is done safely is a must. Although I argue that if there is such a risk and minimal benefit with these methods why even do them at all (source).
Another skill all manual therapists need is the ability to identify and recognise those presenting with serious pathology masquerading as musculoskeletal pain.
Lastly but most importantly, all manual therapist needs skill in interaction!
Being able to connect, relax, reassure and calm people is a ‘skill’ not to be taken for granted. It’s this skill combined with simple, confident, comfortable handling skills that I truly believe distinguishes a great manual therapist from a good one, not any Jedi abilities, qualifications or recent courses they have attended.
Fighting against the tide!
So there you go, my explanation of why I think there is NO technical skill in manual therapy. Even if we could assess accurately and reliably a stiff joint, a muscle knot or some other structural fault, all the effects of manual therapy are not structural, so it really doesnt matter how you or where you press or poke someone, it only matters to the patient and so they need to tell and guide you as what and where to go.
Manual therapy’s effects are due to a host of non specific psychological and neurological factors that do require some skill in acquiring and some understanding and awareness of.
So this is my own story of my desire and passion to learn about manual therapy followed by my disillusion and disenchantment by the nonsense and rubbish surrounding it. I now find myself (unexpectedly) as a cynical, skeptical and often misunderstood critique of manual therapy for which I’m hoping this blog will provide some clarity of where I am coming from.
Let me also state once more that my aim is not to put people completely off manual therapy nor negate or belittle the non specific effects of human touch, or say that manual therapy doesn’t have a role or place in rehab.
Instead my aim is to try and debunk the biased, flawed and general crap that surrounds it, and to be a thorn in the side for the few unscrupulous manual therapy ‘guru’s’ pedalling their courses and pushing their fanciful teachings and wild claims for profit rather than helping patients.
Unfortunately, I seem to be doing this more and more as the greedy and at times immoral, manual therapy industry continues to grow into an ugly profit driven commercial business, motivated more by money than outcomes, feeding off patients in pain and with injury, feeding off well meaning therapists wanting to help who get sucked in to all the courses, workshops, manuals, books, DVDs, and seminars.
So please expect to hear me rant, moan and wail on this subject for while longer.
As always thanks for reading